Battling Workers Compensation Fraud

Way too often, the field of workers compensation is seen as a mixture of interrelated chain of events that only happen on a somewhat coordinated basis. Parties involved in this line of claims handling see themselves as having “their” area of responsibility in hopes that their part will somehow fit into the final analysis. Workers compensation claims are more than just 1,000 moving parts—they are an opportunity that demands structure. In truth, the structure can be well planned and coordinated when seen in a structured paradigm.

Simply put, claims and fraud investigations are best seen as a game of chess. Each move has meaning, and mistakes are costly. A lack of a well-planned and coordinated attack will almost always leave you at a loss. In the case of workers compensation claims, your opponent will not just simply capture your king—he will capture your dollars, too.

Much as the original Star Trek series had Spock playing an odd-looking, tiered game of chess, so exists your modern workers compensation claim. The different boards in play at the same time correspond to the legal, investigative, and customer relations areas of claims handling. While each “board” has the same appearance, to play one and ignore another is horribly foolish. The same is true when handling workers compensation claims. If the legal or investigative component of your workers compensation team operates in a vacuum to any degree, then it will inevitably cause significant damage to another part of your claims handling efforts.

However, in an experienced and mature claims handling effort, the task is much more than just avoiding a mistake. Just as in chess, it is about capitalizing on your opponent’s lack of planning or judgment. For instance, when a claims investigator notices irregularities during an investigation, does he keep the defense counsel advised on a real-time basis? Is the legal defense informing the investigator on what may be of crucial issue in an upcoming deposition? If not, one part of your workers compensation claims team is creating variability for another part of your team. This variability equals lack of coordination and subsequent vulnerability.

I often explain it this way to new claims investigators and handlers: While Star Trek’s chessboards are perpendicular and somewhat offset, they still maintain an overlapping pole that runs through them. That connecting center line represents coordination. Without the connection between the playing boards, you have effectively cut off a significant portion of your claims handling capability. Even the newest workers compensation staff members would agree that this is a losing proposition.

As in any contest, it’s important to recognize the skill and weakness of your counterpart. Better to arrive with an overly healthy respect for your claimant and the skills of his counsel than to underestimate and be surprised. A good adversary will beat you; a great adversary will get you to beat yourself by presenting you opportunities to lose. Such examples include allowing possible faults to show in the facts of loss while knowing the non-apparent answers, and presenting a convincing set of facts of loss and persuading you to reply on the apparent sincerity of the story instead of fact-checking with your own comprehensive investigation.

While we now can easily visualize the inherent coordination link between the claims handling components, it is equally important that we appreciate the need, at times, to have the departments act independently. However, independence from one another does not mean blindness to nearby action, but rather that one action may not be causally linked to another. For instance, your light-duty assignment for the injured worker should not be linked to any displeasure regarding his recent litigation pleading. While certainly being on the claims team will make you privy to actions within the workers compensation file, a clear and clean independence, at times, is paramount.

One of the biggest mistakes that experienced workers compensation claims personnel make is becoming friends with apathy. It is an absolute killer of inventiveness. Once you stop creatively strategizing, you put a limitation on not only your ability to further investigate a case, but also you invite your adversaries to not work as hard to prove their cases. If you can smell lack of preparation on your adversary, then he can smell it on you. Moreover, if you always take the initiative to show pride in your craft, then you will never have to look very hard to see the results of it in your workers compensation claims investigations. It should be the first thing anyone notices.

Just as an avid and keen player of chess grows better with time, so should your effort and skill at fighting workers compensation fraud. Continuous learning is the lifeblood of an effective existence. Do you know exactly what a medical canvass is, and how many times you have employed it in the last year? How many times have you utilized a social media check on a claimant? Do you take the time to recheck their social media later in the claim before settlement? These are all techniques that are indispensable in battling malingering and health care fraud. Good claims management utilizes these tools; great claims management masters them.

Finally, like many things in life, the tiered chessboard conceptualization of workers compensation claims demands that one never loses sight of the forest for the trees. Don’t be mesmerized by the side to side and up or down movements of all the pieces in a claim. A claim that obviously needs to be paid should be; moving pieces around won’t change that. On the other hand, a claim that needs it should be investigated. Never let the movement and flow of the claim get in the way of good, common-sense claims handling. In the end, it’s always the reasonability of your claims decisions that will rule the day, not just the number of moves within a claim that it took to arrive at the decision point.

While the handling of workers compensation claims will never be easy, with the understanding of how the claims handling components exist, relate, and appear in a bigger picture, it is easier to manage the strategies to most effectively handle them.